Orthodontic Appointment Request Form

If you prefer, you can call our office for an appointment. Reach us at 951-693-9373 and ask for the specific office you'd like to receive service in. We have Offices in Hemet, Murrieta, and Temecula.

To schedule an Orthodontic Appointment you can use the following form:

Patient Name (required)

New Patient?

Promo Code

Your Email (required)

Phone Number


Convenient Times

Preferred Days

How did you hear about our office?

How did you find our website?

Additional Comments or Specific Requests

We appreciate you taking the time to fill out this form to request an orthodontic Appointment. We value your time and efforts and will do our best to contact you in a quick efficient manner. We look forward to working with you to meet your Orthodontic goals and help you or your loved one achieve the smile you desire. You may also contact us by visiting our Contact Page and choosing the office that suits your needs best.

We have three conveniently located offices to serve you in Hemet, Temecula and Murrieta. our staff is always able to help you through whatever concerns you might have and Drs. Jergensen and Waddoups are Professionals who truly love what they are doing on a daily basis. Your Orthodontic goals are our goals and we look forward to making your experience comfortable and providing you with the end result you've been dreaming of: A gorgeous smile that you're proud of.